Evidence Synthesis Program (ESP) Center
Durham VA Healthcare System
Jennifer M. Gierisch, PhD, MPH, Co-Director
Karen M. Goldstein, MD, MSPH, Co-Director
Rushton S, Boggan JC, Lewinski AA, Gordon AM, Shoup JP, Van Voorhees
E, Whited JD, Alishahi Tabriz A, Adam S, Fulton J, Kosinski AS, Van Noord MG, Williams JW Jr,
Goldstein KM, Gierisch JM. Effectiveness of Remote Triage: A Systematic Review. Washington, DC:
Evidence Synthesis Program, Health Services Research and Development Service, Office of Research
and Development, Department of Veterans Affairs. VA ESP Project #09-010; 2019.
The US health care system currently faces several challenges including caring for an increasing
elderly population, a large numbers of patients with multiple chronic conditions, and an uneven
distribution of primary care providers across the country. The full appointment schedules of
many primary care physicians compound this workforce shortage, making it challenging for
many patients to access acute and chronic care within a primary care setting. Additionally, many
patients experience multiple structural, financial, and logistical barriers to receiving timely care.
In rural areas, for example, patients face challenges posed by distance to providers, decreased
numbers of providers, and a lack of public transportation infrastructure to facilitate attending
Such access challenges may lead people to seek acute or chronic care in settings such as
emergency departments (EDs) when their needs could have likely been addressed in a primary
care setting. Increasingly, acute care visits take place outside of the primary care setting. Yet
patients who have access to after-hours care at their usual primary care practice have lower rates
of higher level care utilization. One way of providing patient access to the appropriate level of
care is through technology-based systems that facilitate remote decision-making. Remote
decision-making is defined as making clinical decisions in the absence of a face-to-face
encounter. Further, remote decision-making can overcome barriers such as demand for in-person
The implementation of any technology-based system is complex and requires evaluation of many
factors at the patient, provider, and organizational levels. Factors related to the successful
planning of such a system include the specific clinical and population contexts, the ability to
sustain the process, and legal considerations around remote medical decision-making. Specific
issues related to the execution of such a system include adaptability, complexity of the system,
costs, external forces like incentives, and internal forces like supportive resources. Such systems
have been successfully implemented in the United Kingdom, where patients requesting a sameday
appointment by telephone are assessed and triaged to the appropriate level of care. Prior
systematic reviews have reported that more research is necessary to determine the impact of
triage and telephone consultation with patients on clinical outcomes, costs, and subsequent care
As the country's largest integrated health system, the Veterans Health Administration (VHA) has
a mandate to care for Veterans across the entire United States and associated territories. Veterans
established within VA may still experience barriers to accessing care, including multiple health
comorbidities that limit travel, transportation concerns, or the need to access care after normal
primary clinic hours. Thus, technology-based solutions to improve access are of significant
interest in meeting VA's responsibility "to care for [those] who shall have borne the battle."
Additionally, the recently passed MISSION Act specifically identifies telehealth via telephone or
computer as channels for Veterans to receive timely care. At the request of the VA Office of
Connected Care, we therefore conducted a systematic review to address the following key
A. For adults, what are the effects of remote triage on health care utilization, case resolution,
patient safety, patient satisfaction, and cost?
B. What is the impact of remote triage by different modalities (eg, telephone, video, web,
short message service [SMS])?
KQ 2: What are the identified best practices that impact the planning, execution, and evaluation
of remote triage for adults seeking clinical care advice in a large-scale health system such
as the VA?
KQ 3: What are the types of outcomes used to assess the impact of remote triage?
Boggan J, Shoup J, Whited J, et al. Effectiveness of Acute Care Remote Triage Systems: a Systematic Review. Journal of General Internal Medicine. Published online January 2, 2020. doi:10.1007/s11606-019-05585-4